Acute pyogenic diskitis (spondylodiskitis) in adults

Most cases of back pain are the result of degenerative changes in the spine or are related to musculoskeletal elements. Pyogenic infections of the back can be subcategorized into cases involving the paraspinal epidural space, vertebral bodies, or the intervertebral disk spaces. Any region of the spine may be the site of diskitis, although the process most commonly involves the lumbar spine. Most cases of diskitis are managed with conservative therapy, including antibiotics and spinal immobilization using braces or corsets. Surgical therapy is generally reserved for patients with neurological complications, spinal instability, or progressive spinal deformity or those who fail to respond clinically to antibiotic therapy alone.

The fate of anterior autogenous bone graft after anterior radical surgery with or without posterior instrumentation in the treatment of pyogenic lumbar spondylodiscitis

STUDY DESIGN

A retrospective clinical study.

OBJECTIVE

To assess the results of anterior strut grafting and the loss of the reduction in anterior interbody fusion and anterior interbody fusion combined with posterior instrumental fusion in pyogenic spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Resorption of the anterior graft is an ominous sign following most anterior surgery. Thus, additional posterior instrumentation has been used to prevent collapse of the anterior graft. However, its effect is controversial, and few studies have examined the fate of the anterior strut graft.

METHODS

Twenty-four consecutive patients underwent surgical treatment for pyogenic spondylodiscitis. The patients were divided into Group I (anterior interbody fusion) and Group II (anterior interbody fusion + posterior instrumented fusion). The sagittal angle, intervertebral height, and complications relating to the anterior graft were compared.

RESULTS

Solid bone fusion was achieved in 23 (95.8%) patients. The sagittal angle and the intervertebral height were similar in Groups I and II (P = 0.61, P = 0.89, respectively). In Groups I and II, the postoperative sagittal angle was maintained until 1 month after surgery (P > 0.05), but it decreased significantly by 3 months after surgery (P < 0.05). In Groups I and II, intervertebral height correction was maintained until 1 month after surgery (P > 0.05), but by 3 months after surgery, it had collapsed significantly (P < 0.05). Subsidence of the graft occurred through the damaged endplate. Group I included 1 case of graft dislodgement necessitating revision; there were no such cases in Group II. There were no recurrences of infection in either group.

CONCLUSION

Reduction of intervertebral height and loss of sagittal profile occurred in both groups. Complications relating to the bone graft were more common in Group I than in Group II. Despite loss of correction, both groups had a high fusion rate without recurrence of infection. The reduction of intervertebral graft height appears to be the result of destruction of the endplate either due to surgical debridement or the infective process.

A less invasive posterior approach for the management of extended secondary epidural abscess technical note

Spondylodiscitis is considered to be the main cause of epidural abscess. In this report, the authors present their concept for the management of the extended epidural abscess that occurs in combination with spondylodiscitis. It consists of debridement and fusion for spondylodiscitis together with epidural abscess drainage using a microscopically assisted percutaneous technique. In the period from April 2000 to April 2004, 5 patients with spondylodiscitis and an accompanying extended epidural abscess were operated on. The mean age of the patients was 66 years. There were 4 males and one female. The follow-up period ranged from 3-12 months. To manage the extended epidural abscess, the authors created one or two drainage sites along the extension of epidural abscess. These drainage sites were made using a microscopically assisted percutaneous approach. In all presented cases, the offending organism was Staphylococcus aureus. The postoperative infection markers showed marked regression. The postoperative control MRI demonstrated effective drainage of the extended epidural abscess. Regarding the neurological deficits, 3 patients previously classified as Frankel C showed an improvement to Frankel E within 3 months postoperatively. From these results, it seems that our technique (ventro-dorsal abscess drainage combined with a microscopically assisted percutaneous approach) could be a successful method for the management of the extended epidural abscess associated with spondylodiscitis.

Intramedullary spinal cord abscess complicating thoracic spondylodiscitis caused by Bacteroides fragilis

Intramedullary spinal cord abscess associated with infectious spondylodiscitis is a rare entity. The case of a 66-year-old man with an intramedullary spinal cord abscess complicating thoracic spondylodiscitis is presented. The patient was unable to ambulate independently due to weakness of the legs. MR imaging showed findings suggestive of infectious spondylodiscitis at the T5-T6 level associated with epidural and intramedullary spinal cord abscesses. Biopsy of the intervertebral disc was performed and Bacteroides fragilis was isolated. Antibiotic therapy was instituted, and MR imaging of the thoracic spine was performed 6 weeks after the initiation of treatment, showing resolution of the epidural and intramedullary spinal cord abscesses.

Recurrent acute low back pain secondary to lumbar epidural calcification

INTRODUCTION

Epidural calcification is a rare cause of back pain, and spontaneous epidural calcification has not been reported previously.

CASE REPORT

We describe a patient with acute low back pain and signs of lumbar nerve root compression due to epidural calcification, as demonstrated by CT-scan and MRI. Radiological signs of spondylodiscitis led to a search for an infectious cause, which was negative, and her symptoms responded rapidly to NSAID treatment alone. Her symptoms recurred 18 months later, and further imaging studies again revealed epidural calcification, but with a changed distribution. Her symptoms were relieved once more by NSAID treatment alone.

DISCUSSION

We propose that epidural calcification secondary to aseptic spondylodiscitis is the main cause of acute back pain in this patient. A possible mechanism may be the pro-inflammatory effects of calcium pyrophosphate or hydroxyapatite crystal deposition within the epidural space.

A case of lumbar sciatica in a patient with spondylolysis and spondylolysthesis and underlying misdiagnosed brucellar discitis

We report the case of a patient affected by vertebral pain refractory to conventional analgesic therapy with a diagnosis of spondylolysthesis and also the affects of a misdiagnosed brucellar spondylodiscitis. The absence of a positive response to conventional analgesics, a suggestive medical history (epidemiologic data still show a high incidence of Brucella infections for the Province of Catania), radiological findings and microbiological tests led to the correct diagnosis of algic syndrome in a patient affected by brucellar spondylodiscitis with the concomitant presence of retroperitoneal muscular abscess, and a previously diagnosed spondylolysthesis. All symptoms improved after correct antibrucellar antibiotic therapy and surgical drainage of the retroperitoneal abscess. Vertebral pain is a relatively frequent symptom observed in Pain Medicine Services; in a zone in which Brucella infections may be considered endemic, neurobrucellosis must be considered highly probable in the differential diagnosis of several clinical pictures, including vertebral pain that could result from vertebral localization of Brucella infection. The role of the Pain Medicine Specialist is not only to treat the symptoms, but also to research and confirm the etiopathogenetic mechanisms before starting a correct treatment.

[A tenacious lameness in a 2-year-old child]

Spondylodiscitis, a septic infection of the intervertebral disc Spondylodiscitis, a septic infection of the intervertebral disc and adjacent vertebrae, is an unusual infection, mainly affecting children and elderly people. It is classically associated with tuberculosis, but other germs such as Staphylococcus aureus, Streptococcus pyogenes or mitis, and some even more unususal ones (e.g. Kingella kingae), are often encountered in our countries. Non tuberculous spondylodiscitis is found in approximately 2% of pediatric bone infections. Medullar compression and bone destruction can occur, especially when diagnosis is delayed, hence the value of early diagnosis and treatment. We report the case of a non tuberculous spondylodiscitis occurring in a 22 month-old baby

[Syrinx formation secondary to cervical epidural abscess]

We report a patient with syrinx formation secondary to cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. A 53-year-old woman developed sudden fever, headache and neck pain. On admission, neurological evaluation showed limitation of cervical motion, meningeal irritation, and exaggerated muscle stretch reflexes in all four extremities. Cerebrospinal fluid cell count was 832/mm3 and protein was 771 mg/dl. Bacterial culture of the cerebrospinal fluid showed Staphylococcus aureus. A cervical MRI scan with Gd-enhancement revealed focal high intensity signal in the T2-weighted and FLAIR images, at the anterior meninges of the C3-8 segments, the vertebral bodies of C5-6 and the intervertebral disks of C5-6 segment. Her diagnosis was cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. Antibiotics and steroids improved her symptoms. Six weeks after the onset of symptoms, a cervical MRI scan showed narrowing and synarthrosis in the intervertebral space between C5 and C6. MRI and myelo CT scans demonstrated a newly-formed syrinx from C3-C 7. This was an interesting case of syrinx formation secondary to cervical epidural abscess.

Fever of unknown origin: A case report of brucellar discitis

Introduction Febrile episodes of unknown origin lasting for two weeks require detailed investigation by various medical specialists. Fever of unknown origin is most commonly caused by infections, malignancy, colagenosis and in 5-10% of cases, despite detailed diagnostic assessment, the cause remains unknown. In cases of fever of unknown origin, the diagnostic procedures are difficult and complex. Case report This is a case report of brucellar discitis in a female patient treated at the Clinic of Endocrinology, Diabetes and Metabolic Diseases with a diagnosis of fever of unknown origin. Her laboratory findings revealed high erythrocyte sedimentation rate, anemia and high gamma globulin fractions. The patient underwent radiology examination and a suspicion of infection was defined, which was later confirmed by additional tests. Conclusion Despite the fact that the diagnostic investigations of patients with fever of unknown origin are complex and time consuming, detection of the cause is of utmost importance and it is a prerequisite for successful therapy.

[Low back pain with 'red flags': a case of spondylodiscitis]

Spondylodiscitis is a serious clinical entity. Despite the decrease in mortality from about 25% in the pre-antibiotic era to near 5%, it remains significant and the associated morbidity is still relevant. The rate of residual neurological deficits among survivors is around 7%. In 30% of patients some related symptoms persist, the most important being pain. The authors report the case of a 74-year-old male patient with recent onset low back pain, which caused considerable disability. With this work the authors intend to alert to the fact that in a patient with a common symptom such as low back pain, the presence of "red flags" requires a quick investigation and diagnosis in order to prevent serious damage.

Lumbar false aneurysms following image-guided interventive procedures for spondylodiskitic abscesses

Pseudoaneurysms of the lumbar arteries are infrequent, and are most often found incidentally after trauma to the lumbar spine. More rarely, they are an iatrogenic complication from diagnostic or therapeutic procedures, particularly of the kidney. Their rupture can cause rapid clinical deterioration by retroperitoneal hemorrhage, and therefore their diagnosis and treatment must be rapid. We report two cases of lumbar artery false aneurysms arising as a complication during the treatment of infectious disciitis. The diagnoses were established via CT and immediately followed by expeditious treatment by selective arterial embolization.

Les abcès pyogènes secondaires du psoas : à propos de six cas et revue de la littérature

PURPOSE

Psoas abscess is a rare disease in developed countries. Its diagnosis is difficult and any delay could lead to a worsen prognosis. The aim of this study is to determine the best diagnostic and therapeutic practices.

METHODS

A retrospective study of psoas abscess that occurred during six months was performed.

RESULTS

Six cases of secondary psoas abscess are reported. They were associated with spondylodiscitis in three cases, arthritis and gynaecologic infection in the three remaining cases. Anatomic diagnosis was performed by tomodensitometry. Microbiologic diagnosis was obtained by blood culture or direct puncture of the abscess. Antibiotics were associated with percutaneous drainage in two cases, with simple puncture in one case, and with surgery in one case. A local improvement w observed in all cases. The oldest patients presented the worst complications which were not directly caused by the abscess.

CONCLUSION

Physicians must be aware of psoas abscess because of their increasing incidence. Despite the fact that digestive pathologies are the main cause of secondary psoas abscess, bone infections, particularly spine infections, should be taken into consideration. Tomodensitometry guided puncture or percutaneous drainage are of diagnostic and therapeutic interest. Infectious samples must be taken before starting antibiotics, which have to be efficient against Gram negative bacillus, anaerobes and Staphylococcus aureus. Surgery must be quickly performed when the primary infection localisation need it, in case of voluminous abscess or when antibiotics and drainage are inefficient.

Endovaskuläre Therapie eines Aneurysma der thorakoabdominellen Aorta bei einer spezifischen Aortitis

Wir berichten über die erfolgreiche endovaskuläre Therapie bei einer 63-jährige Patientin mit einem Aortenaneurysma der thorakoabdominellen Aorta, das unmittelbar cranial des Truncus coeliacus gelegen war. Ursache des inflammatorischen Aneurysmas war eine Spondylodiszitis auf Höhe des 12. Brustwirbels und des 1. Lendenwirbels. Da die Gefäßchirurgen eine operative Behandlung ablehnten, wurde gemeinsam von transfemoral eine endovaskuläre Therapie mit einem Stentgraft durchgeführt, um das Aneurysma bei regelrechter Durchgängigkeit der Viszeralarterien und der A. Adamkiewicz auszuschalten. Ein kultureller Nachweis des Erregers erfolgte nicht. Unter Antibiose und Cortisontherapie war das inflammatorische Aneurysma nach drei Monaten nicht mehr nachweisbar, die Spondylodiszitis weitgehend zurückgebildet.

[A vascular pedicled duplicated fibula transplant for treatment of lumbar instability following tuberculous spondylodiscitis]

Operative treatment of tuberculous spondylodiscitis is still an important part of the treatment for lumbar spine instability. We report on a patient who suffered an extensive relapse with microbiological confirmation of tuberculous spondylodiscitis following operative spinal treatment for unspecific spondylodiscitis. X-Ray examination showed development of pronounced lumbar instability, which was first treated with the aid of an external fixateur and later by means of a doubled fibular bone graft with a vascularised stem with no dorsal instrumentation, which led to bony consolidation.

Acute red eye and back pain as a presentation for systemic illness: case report

Background

Acute red eye is a common presentation in both primary and secondary care. Presentation in combination with other systemic symptoms can indicate serious underlying pathology.

Case presentation

73-year-old lady presenting with endogenous endophthalmitis and thoracic discitis secondary to sub-acute bacterial endocarditis.

Conclusion

Acute red eye in combination with systemic symptoms requires immediate investigation. If endogenous endophthalmitis is diagnosed, a source of sepsis should be comprehensively investigated and referral made to individual specialities if necessary.

Surgical treatment with spinal instrumentation for pyogenic spondylodiscitis due to methicillin-resistant Staphylococcus aureus (MRSA): a report of five cases

INTRODUCTION

The treatment of methicillin-resistant Staphylococcus aureus (MRSA) spondylodiscitis is reported to be far more difficult than that of non-MRSA spondylodiscitis. At present, there seems to be no standard protocol for the treatment of MRSA spondylodiscitis cases in which conservative management has failed.

MATERIALS AND METHODS

Between 1998 and 2001, five patients (aged 48-73 years; average: 63.8 years; SD: 9.9) with MRSA spondylodiscitis were treated surgically after conservative treatment had failed. Posterior spinal instrumentation was performed for all five patients, three of whom also underwent anterior debridement and bone graft. All the patients had neurological deficits and severe pain. To assess the invasiveness of the operation, we evaluated operating time, blood loss, and complications. Pain (verbal rating scale; VRS), neurological status (Frankel type), activities of daily living (ADL) (the Barthel index), WBC, CRP, and ESR in the preoperative, postoperative and final follow-up periods were used to evaluate the surgical outcomes.

RESULTS

Although we encountered several postoperative complications including deep wound infections, at the final follow-up visit, the neurological deficits, activities of daily living, Barthel index, and VRS had improved in all the patients. Changes in WBC, CRP, and ESR revealed suppression of infection in all patients.

CONCLUSION

Surgical treatment for MRSA spondylodiscitis with posterior spinal instrumentation provided patients with satisfactory final outcomes.

Abscesos del psoas. Una perspectiva actual

OBJECTIVE

To analyze the characteristics of abscesses of the psoas muscle and assess the differences between pyogenic and tuberculous abscesses.

METHODS

Retrospective descriptive study of all patients with psoas abscess in our hospital over the period 1994 to 2004.

RESULTS

Fourteen patients were studied (10 males), with a mean age of 42 years. Half of them had had an underlying disease. The most frequent clinical manifestations were abdominal pain (64%), fever (57%), and back pain (43%). All the abscesses were secondary. In 7 patients the origin was gastrointestinal, in 6 osteoarticular, and 1 was related with infection of an aortobifemoral bypass. Computed tomography was the diagnostic imaging method in all patients. Culture of drainage specimens was positive in 92% of patients undergoing this procedure. Causal microorganisms included Mycobacterium tuberculosis (5), Streptococcus intermedius (4), Staphylococcus aureus (3), Escherichia coli (3) and Bacteroides fragilis (2). Tuberculous abscesses originated in spondylitis and the clinical presentation was longer prior to diagnosis. Drainage was performed in 12 patients (8 percutaneous and 4 surgical). Mean duration of antimicrobial therapy was 4 weeks. The infection resolved in all patients.

CONCLUSIONS

Psoas abscess commonly had a gastrointestinal and osteoarticular origin. We underscore the high percentage of tuberculous etiology, which had a more insidious clinical and analytical presentation and was usually secondary to spondylitis. Prolonged antimicrobial treatment associated with drainage was effective therapy.

[Spondylitis/spondylodiscitis]

Spondylitis is an inflammation of the vertebral body. If the infection is manifested in the vertebral motor segment it is called spondylodiscitis, which can be divided into specific and nonspecific forms. It is clinically impressive that at the beginning of the disease, the patients who are quite often immunosuppressed suffer from localized, especially nocturnally exacerbated backache. The initial diagnostic work-up generally consists of clinical history, examination, laboratory tests, and (especially advanced) imaging findings. Although computed tomography still remains the most frequently used advanced imaging technique, magnetic resonance imaging is the golden standard for the diagnosis of spondylitis and spondylodiscitis.

[Idiopathic intervertebral disc calcification in children: the role of diagnostic imaging. A case report]

The idiopathic calcification of the intervertebral disc in childhood is a rare syndrome with unknown aetiology. This pathology is more frequent in males, with predominant localization to cervical spine. The natural evolution of the syndrome is the progressive and spontaneous resorption of the calcific deposit, with symptom regression. We report a case of an acute and worsening torticollis in a 10-year-old child, with reference to a recent minor cervical distortion, resistant to analgesic treatment. X-ray evaluation, executed after a week from the appearance of torticollis, showed an oval calcification in the nucleus pulposus of the C6-C7 intervertebral disc. The CT and especially the MRI concurred to recognize a disc hernia and an adjacent osteo-ligamentous pathologic participation. In particular, MRI showed the adjacent vertebral spongy bone edema and the active enthesiopathy of the posterior longitudinal ligament.

An uncommon cause of paraplegia: Salmonella spondylodiskitis

BACKGROUND/OBJECTIVE

Salmonella spondylodiskitis is an uncommon type of vertebral infection. The aim of this study was to present a case of progressive paraplegia caused by Salmonella spondylodiskitis and epidural abscess after endoscopic cholecystectomy.

METHODS

The patient underwent posterior instrumentation and posterior fusion between T6 and T12, hemilaminotomies at levels T8-T9-T10, and drainage of the abscess. Through a left thoracotomy, anterior T8-T10 corpectomy, debridement, anterior stabilization, and fusion were conducted.

RESULTS

Fifteen months later, final follow-up showed no complications secondary to the vertebral and hip surgeries, and neurological status improved to Frankel grade E. Laboratory investigations showed no evidence of Salmonella infection.

CONCLUSION

Immunocompromised patients who undergo endoscopic intervention are vulnerable to Salmonella infections. One must consider Salmonella infection in those who develop acute progressive spondylodiskitis.